This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). EB CME is clinical content presented with practice recommendations supported by evidence that has been systematically reviewed by an AAFP-approved source. The evidence is available at
http://www.clinicalevidence.com/ceweb/conditions/msd/1118/1118.jsp.

UNKNOWN EFFECTIVENESS

Analgesics

We found no systematic review or randomized controlled trial (RCT) on the use of analgesics for treatment of persons with symptomatic herniated lumbar disks.

Antidepressants

We found no systematic review or RCT on the use of antidepressants for the treatment of persons with symptomatic herniated lumbar disks.

Muscle Relaxants

We found no systematic review or RCT on the use of muscle relaxants for the treatment of persons with symptomatic herniated lumbar disks.

Corticosteroids (Epidural Injections)

One systematic review provided limited evidence that epidural corticosteroid injections increased global improvement compared with placebo. However, a subsequent RCT showed no significant difference between epidural corticosteroid injections plus conservative treatment and conservative treatment alone in pain, mobility, or ability to return to work at six months. Another subsequent RCT showed no significant difference between epidural corticosteroid injection and control injection in pain, disability, or self-rated improvement after 35 days. One RCT provided limited evidence that epidural corticosteroid injections were less effective at reducing leg pain and improving function than standard diskectomy at one to three months but showed no significant differences between these treatments at two and three years.

What are the effects of nondrug treatments?

LIKELY TO BE BENEFICIAL

Spinal Manipulation

One RCT, identified by a systematic review that included persons with sciatica caused by disk herniation, showed that spinal manipulation increased self-perceived improvement after two weeks compared with a placebo of infrequent infrared heat. Another RCT identified by the review that compared spinal manipulation, manual traction, exercise, and corsets showed no significant difference among groups in self-perceived improvement at one month. One subsequent RCT showed that spinal manipulation increased the number of persons with improved symptoms compared with traction. Concerns exist about possible further herniation from spinal manipulation in surgical candidates.

UNLIKELY TO BE BENEFICIAL

Bed Rest

One systematic review of conservative treatment identified no RCT on bed rest including persons with symptomatic herniated disks. One subsequent RCT that included persons with sciatica showed no significant difference between bed rest and watchful waiting for two weeks in self-perceived improvement or in mean pain, disability, or satisfaction scores after 12 weeks.

Traction

One systematic review showed no significant difference in overall global improvement between traction and placebo in persons with sciatica and herniated lumbar disks. One small RCT identified by the review showed no significant difference in global measure of improvement between manual traction and isometric exercises in persons with herniated lumbar disks. Another RCT identified by the review that compared spinal manipulation, manual traction, exercise, and corsets showed no significant difference among groups in self-perceived improvement after one month. One small RCT identified by the review showed no significant difference in overall global improvement between autotraction and manual traction. Another small RCT identified by the review provided limited evidence that autotraction increased the proportion of persons reporting a response immediately after treatment compared with passive traction.

UNKNOWN EFFECTIVENESS

Advice to Stay Active

One systematic review of conservative treatments for sciatica caused by lumbar disk herniation identified no RCT on advice to stay active.

Massage

One systematic review identified no RCT on massage in persons with symptomatic lumbar disk herniation.

Heat or Ice

One systematic review identified no RCT on heat or ice for sciatica caused by lumbar disk herniation.

Exercise Therapy

We found no systematic review or RCT comparing exercise therapy with placebo or no treatment. One small RCT identified by a systematic review showed no significant difference in global improvement between isometric exercise and manual traction in persons with sciatica caused by disk herniation. Another RCT identified by the review that compared spinal manipulation, manual traction, exercise, and corsets showed no significant difference among groups in self-perceived improvement after one month.

Acupuncture

One systematic review showed that there was insufficient evidence on the effects of acupuncture in persons with herniated lumbar disks.

What are the effects of surgery?

LIKELY TO BE BENEFICIAL

Standard Diskectomy (Short-term Benefit)

One RCT showed that standard diskectomy increased self-reported improvement at one year but not at four and 10 years compared with conservative treatment (physiotherapy). One RCT provided limited evidence that standard diskectomy improved leg pain and function at one to three months compared with epidural corticosteroid injections. The RCT showed no significant difference between treatments after two to three years. Three RCTs showed no significant difference in clinical outcomes between standard diskectomy and microdiskectomy. Adverse effects were similar with both procedures. One RCT showed no significant difference in satisfaction or pain between standard diskectomy and video-assisted arthroscopic microdiskectomy at about 30 months, although postoperative recovery was slower with standard diskectomy.

Microdiskectomy (as Effective as Standard Diskectomy)

We found no RCT comparing microdiskectomy with conservative treatment. Three RCTs showed no significant difference in clinical outcomes between microdiskectomy and standard diskectomy. One RCT showed no significant difference in satisfaction or pain between video-assisted arthroscopic microdiskectomy and standard diskectomy at about 30 months, although postoperative recovery was slower with standard diskectomy. Two RCTs identified by a systematic review provided insufficient evidence on the effects of automated percutaneous diskectomy compared with microdiskectomy.

UNKNOWN EFFECTIVENESS

Automated Percutaneous Diskectomy

We found no RCT comparing automated percutaneous diskectomy with conservative treatment or standard diskectomy. Two RCTs identified by a systematic review provided insufficient evidence on the clinical effects of automated percutaneous diskectomy compared with microdiskectomy.

Laser Diskectomy

We found no systematic review or RCT on the use of laser diskectomy for treatment of persons with symptomatic herniated lumbar disks.

Definition

Herniated lumbar disk is a displacement of disk material (nucleus pulposus or annulus fibrosis) beyond the intervertebral disk space.1 The diagnosis can be confirmed with radiography; however, magnetic resonance imaging findings of herniated disk are not always accompanied by clinical symptoms.2,3 This chapter covers the treatment of persons with clinical symptoms relating to confirmed or suspected disk herniation. It does not include treatment of persons with spinal cord compression or cauda equina syndrome, which require emergency intervention. The management of nonspecific acute and chronic low back pain is covered in another chapter of Clinical Evidence.

Incidence

The prevalence of symptomatic herniated lumbar disk is about 1 to 3 percent in Finland and Italy, depending on age and sex.4 The highest prevalence is among persons 30 to 50 years of age5 with a male-to-female ratio of 2:1.6 In persons 25 to 55 years of age, about 95 percent of herniated disks occur at the lower lumbar spine (L4–5 level); disk herniation above this level is more common in persons older than 55 years.7,8

Etiology

Radiographic evidence of disk herniation does not reliably predict future low back pain or correlate with symptoms; 19 to 27 percent of asymptomatic persons have disk herniation on imaging.2,9 Risk factors for disk herniation include smoking (odds ratio [OR] 1.7; 95% confidence interval [CI], 1.0 to 2.5); weight-bearing sports (e.g., weight lifting, hammer throw); and certain work activities (e.g., repeated lifting). It has been suggested that driving a motor vehicle is a risk factor for disk herniation, although evidence is not conclusive (OR 1.7; 95% CI, 0.2 to 2.7).6,10,11 This potential effect may be because the resonant frequency of the spine is similar to that of certain vehicles.

Prognosis

The natural history of disk herniation is difficult to determine because most persons receive some form of treatment for their back pain, and there is not always a formal diagnosis.6 Clinical improvement is usual in most persons, and only about 10 percent still have pain sufficient enough to consider surgery after six weeks. Sequential magnetic resonance images have shown that the herniated portion of the disk tends to regress over time, with partial to complete resolution after six months in two thirds of persons.12

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REFERENCES

1. Fardon DF,
Milette PC.
Nomenclature and classification of lumbar disk pathology: recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology. Spine.
2001;26:93–113.

2. Boden SD.
The use of radiographic imaging studies in the evaluation of patients who have degenerative disorders of the lumbar spine. J Bone Joint Surg Am.
1996;78:114–25.

This is one in a series of chapters excerpted from Clinical Evidence Concise, published by the BMJ Publishing Group, Tavistock Square, London, United Kingdom. Clinical Evidence Concise is published in print twice a year and is updated monthly online. Each topic is revised every 12 months, and subscribers should view the most up-to-date version at
http://www.clinical-evidence.com. If you are interested in contributing to Clinical Evidence, please send an e-mail to
CEcommissioning@bmj.com. This series is part of the AFP’s CME.
See “Clinical Quiz” on page 1149.